A nurse is caring for a client who gave birth 2 hr ago.
The nurse notes that the client's blood pressure is 60/50 mm Hg. Which of the following actions should the nurse take first?.
Evaluate the firmness of the uterus (fundus).
Obtain a type and crossmatch.
Administer oxytocin infusion.
Initiate oxygen therapy by nonrebreather mask.
The Correct Answer is A
The correct answer is choice A.
Choice A rationale:
Evaluating the firmness of the uterus (fundus) is the first action the nurse should take when a client’s blood pressure drops postpartum. A soft or “boggy” uterus can indicate uterine atony, a leading cause of postpartum hemorrhage, which can lead to hypotension.
Choice B rationale:
Obtaining a type and crossmatch is important if the client needs a blood transfusion, but it is not the first action the nurse should take.
Choice C rationale:
Administering oxytocin infusion can help contract the uterus and control bleeding, but the nurse should first assess the uterus.
Choice D rationale:
Initiating oxygen therapy can help if the client is hypoxic, but the nurse should first assess the uterus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The correct answer is choice A. She did her perineal care independently.
Choice A rationale:
Taking the initiative for caring for her newborn independently while managing her own postpartum needs marks the taking-hold phase of infant bonding.
Choice B rationale:
Being eager to talk about her birth experience is more associated with the taking-in phase, not the taking-hold phase.
Choice C rationale:
Not asking for anything for pain all day is not a specific indicator of the taking-hold phase.
Choice D rationale:
Sitting and rocking her infant for long intervals is not a specific indicator of the taking-hold phase.
Correct Answer is B
Explanation
The correct answer is choice B.
Choice A rationale:
Focus on the family unit and its members is more characteristic of the “letting-go” phase.
Choice B rationale:
Expressions of excitement are common in the dependent, taking in phase as the mother is focused on her own needs and the experience of childbirth.
Choice C rationale:
Eagerness to learn newborn care skills is more characteristic of the “taking-hold” phase.
Choice D rationale:
Lack of appetite is not a typical characteristic of the dependent, taking in phase.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.